Friday, September 30, 2011

[EQ] Expert Review and Proposals for Measurement of Health Inequalities

Expert Review and Proposals for Measurement of Health Inequalities in the European Union

Spinakis A, Anastasiou G, Panousis V, Spiliopoulos K, Palaiologou S, Yfantopoulos J

Full Report. (2011) European Commission

Directorate General for Health and Consumers. Luxembourg. ISBN 978-92-79-18528-1

Full Report available online PDF file [202p.] at:

Summary PDF file [39p.] at:

"…..Monitoring of inequalities in health is an important public health task. Interest in health inequalities among EU countries and their regions as well as among the various social clusters in the EU population is growing.

The search for the best appropriate "summary measure" of health inequality that can be observed individually or in terms of groups of individuals, is a task that occupies a lot the researchers involved in the fields of inequality research.

Lately in the EU, it has been recognized that a more focused effort is required. It is more natural to suggest and construct methodologies or indices that will be suitable for assessing trends in terms of mortality, morbidity and also self-perceived health. The selection of an appropriate indicator or an appropriate measurement methodology for health inequality across the EU-27 countries is a demanding task. Each available indicator has advantages and disadvantages.

Simple indicators are usually comprehensive but may not have some specific desirable characteristics. Other indicators are more technical and difficult to understand, apply and/or interpret, but can assist more in explaining significant components of the concept "health inequality". Complex indicators can also be very useful in the decomposition of inequality. Based on the above, it is reasonable to state that one main goal in the study of health inequalities is to,

- propose appropriate measurement methods in the form of indicators that "estimate" and "capture" the exact level of inequality in a population
  (here the EU population).

The other very important goal of this study is to monitor the variation of health inequalities in all levels of analysis
 (e.g. social groups, regions, individuals) through time. Thus, perform a trend analysis.

The main objective was to contribute in the area of "Monitoring Health Inequalities in the EU", by combining the best practices in health inequalities measurement with the most reliable data that can be used to calculate these measures.

The specific tasks of the project were:

- the review and analysis of the existing work done in the measurement of health inequalities in the EU.

- the review and analysis of the existing and planned data sets available across the EU, with an assessment of their suitability for the purposes of the analysis.



Executive Summary


2. Measurement of Health & Health inequalities in the EU – Conceptual framework

2.1 Health data - Health Indicators

2.2 What is Health Inequality?

2.3 Measurement of health inequality in the EU – A historical review

2.4 Inequality Indicators - Definitions & Classifications

3. Most suitable summary measures for monitoring health inequalities in the EU

3.1 Which indicators do we need? - What do we need to measure?

3.2 Inequalities in mortality across the EU area, regions and time

3.2.1 Proposed Indicators

3.2.2 Inequalities in the EU - Analysis of trends

3.3 Inequalities in Perceived Health Status and other Self Assessed Morbidity by SES groups in the EU

3.3.1 Proposed Indicators

3.3.2 Inequalities in the EU - Analysis of trends

3.4 Inequalities in Disability & Activity Limitations by SES groups in the EU

4. Concluding Remarks


ANNEX I: Index of Tables & Figures

ANNEX II: Tables

ANNEX III: Figures

ANNEX IV: Conceptual Framework to Measurement and Monitoring Health Inequalities

ANNEX V: Classification of Health Inequalities Measurement Techniques

ANNEX VI: Preliminary Evaluation of health Inequality Indicators & Desirable Properties

ANNEX VII: Health Inequalities Measurement by Social Groups - Core Social Variables

ANNEX VIII: EU Survey Tools & Questions




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1 comment:

James Scanlan said...

The document styled “Expert Review and Proposals for Measurement of Health Inequalities in the European Union” is another effort to provide guidance on the measurement of health inequalities that is fundamentally flawed for failure to recognize the way that standard measures of differences between outcome rates tend to be affected by the overall prevalence of an outcome. Most notably, the rarer an outcome, the greater tends to be the relative difference in experiencing it and the smaller tends to be the relative difference in avoiding it. Absolute differences and odds ratios tend also to be affected by the overall prevalence of an outcome, though in a more complicated way. Roughly, as uncommon outcomes become more common, absolute differences between rates tend to increase; as common outcomes become even more common, absolute differences tend to decline. Differences measured by odds ratios tend to change in the opposite direction of absolute differences. About 150 references explaining these patterns in various settings may be found in the Measuring Health Disparities page (MHD) of and discussion of the nuances of the patterns may be found on the Scanlan’s Rule page of the same site. See also references 1-3 below.

Seemingly more sophisticated measures that are functions of dichotomies are likewise problematic for measuring disparities. For example, as an adverse outcome decreases in overall prevalence inequality in experiencing the outcome measured by the concentration index and the Gini coefficient tend to increase while the inequality in avoiding the outcome as measured by those methods tends to decrease. See the Concentration Index and Gini Coefficient sub-pages of MHD.

In discussing the implications of the choice of measure in the appraisal of the size of disparities, the Expert Review document references both (1) Houweling, T.A.J., (2007), Using relative and absolute measures for monitoring health inequalities: experiences from cross-national analyses on maternal and child health., Int. J. for Equity in Health, 6(15), pp1-9 and (2) Masseria, C. (2009), Health inequality: Why is it important and can we actually measure it?, Eurohealth, 15(3), pp4-6. Both of these articles discussed the implications of the overall prevalence of an outcome with regard to the measurement of health inequalities. Yet in going on to make recommendations about particular measures, the document reflects no awareness of the way measures tend to be affected by the overall prevalence of an outcome or the problems such patterns create for the measurement of health inequalities. See discussion of the Houweling and Masseria articles in Section E.7 of MHD.

James P. Scanlan

1. Scanlan JP. Can we actually measure health disparities? Chance 2006:19(2):47-51:

2. Scanlan JP. Race and mortality. Society 2000;37(2):19-35:

3. Scanlan JP. Divining difference. Chance 1994;7(4):38-9,48: